Information for Behavioral Health Providers in Primary Care
Asthma
What is Asthma?
Asthma (AZ-ma) is a chronic (long-term) lung disease that inflames and narrows the
airways. Asthma causes recurring periods of wheezing (a whistling sound when you
breathe), chest tightness, shortness of breath, and coughing. The coughing often
occurs at night or early in the morning.
Asthma affects people of all ages, but it most often starts in childhood. In the United
States, more than 22 million people are known to have asthma. Nearly 6 million of
these people are children.
Overview
The airways are tubes that carry air into and out of the lungs. People who have
asthma have inflamed airways. This makes the airways swollen and very sensitive.
They tend to react strongly to certain substances that are breathed in.
When the airways react, the muscles around them tighten. This causes the airways to
narrow, and less air flows to the lungs. The swelling also can worsen, making the
airways even narrower. Cells in the airways may make more mucus than normal.
Mucus is a sticky, thick liquid that can further narrow the airways.
This chain reaction can result in asthma symptoms. Symptoms can happen each time
the airways are irritated.
Sometimes symptoms are mild and go away on their own or after minimal treatment
with an asthma medicine. At other times, symptoms continue to get worse. When
symptoms get more intense and/or additional symptoms appear, this is an asthma
attack. Asthma attacks also are called flare-ups or exacerbations.
Asthma Information Sheet (continued)
Figure A shows the location of the lungs and airways in the body. Figure B shows a
cross-section of a normal airway. Figure C shows a cross-section of an airway
during asthma symptoms.
.
It's important to treat symptoms when first noticed. This will help prevent the
symptoms from worsening and causing a severe asthma attack. Severe asthma
attacks may require emergency care, and they can cause death.
Outlook
Asthma can't be cured. Even when you feel fine, you still have the disease and it can
flare up at any time. But with today's knowledge and treatments, most people who
have asthma are able to manage the disease. They have few, if any, symptoms.
They can live normal, active lives and sleep through the night without interruption
from asthma. For successful, comprehensive, and ongoing treatment, take an active
role in managing your disease. Build strong partnerships with your doctor and other
clinicians on your health care team.
What Causes Asthma?
The exact cause of asthma isn't known. Researchers think a combination of factors
(family genes and certain environmental exposures) interact to cause asthma to
develop, most often early in life. These factors include:
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An inherited tendency to develop allergies, called atopy (AT-o-pe)
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Asthma Information Sheet (continued)
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Parents who have asthma
Certain respiratory infections during childhood
Contact with some airborne allergens or exposure to some viral infections in
infancy or in early childhood when the immune system is developing
If asthma or atopy runs in your family, exposure to airborne allergens (for
example, house dust mites, cockroaches, and possibly cat or dog dander) and
irritants (for example, tobacco smoke) may make your airways more reactive to
substances in the air you breathe.
Different factors may be more likely to cause asthma in some people than in others.
Researchers continue to explore what causes asthma.
Who is at Risk for Asthma?
Asthma affects people of all ages, but it most often starts in childhood. In the United
States, more than 22 million people are known to have asthma. Nearly 6 million of
these people are children.
Young children, who have frequent episodes of wheezing with respiratory infections,
as well as certain other risk factors, are at the highest risk of developing asthma
that continues beyond 6 years of age. These risk factors include having allergies,
eczema (an allergic skin condition), or parents who have asthma. Among children,
more boys have asthma than girls. But among adults, more women have the disease
than men. It's not clear whether or how sex and sex hormones play a role in causing
asthma.
Most, but not all, people who have asthma have allergies. Some people develop
asthma because of exposure to certain chemical irritants or industrial dusts in the
workplace. This is called occupational asthma.
What are the Signs and Symptoms of Asthma?
Common asthma symptoms include:
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Coughing. Coughing from asthma is often worse at night or early in the
morning, making it hard to sleep.
Wheezing. Wheezing is a whistling or squeaky sound that occurs when
breathing.
Chest tightness. This may feel like something is squeezing or sitting on your
chest.
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Asthma Information Sheet (continued)
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Shortness of breath. Some people who have asthma say they can't catch their
breath or they feel out of breath. They may feel like they can't get air out of
their lungs.
Not all people who have asthma have these symptoms. Likewise, having these
symptoms doesn't always mean that someone has asthma. A lung function test, done
along with a medical history (including type and frequency of symptoms) and
physical exam, is the best way to diagnose asthma for certain.
The types of asthma symptoms, how often they occur, and how severe they are may
vary over time. Sometimes symptoms may just be annoying. Other times they may
be troublesome enough to limit activities of daily living.
Severe symptoms can threaten one’s life. It's vital to treat symptoms when they are
first noticed them so they don't become severe.
With proper treatment, most people who have asthma can expect to have few, if
any, symptoms either during the day or at night.
What Causes Asthma Symptoms to Occur?
A number of things can bring about or worsen asthma symptoms. Your doctor will
help you find out which things (sometimes called triggers) may cause your asthma to
flare up if you come in contact with them. Triggers may include:
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Allergens found in dust, animal fur, cockroaches, mold, and pollens from trees,
grasses, and flowers
Irritants such as cigarette smoke, air pollution, chemicals or dust in the
workplace, compounds in home décor products, and sprays (such as
hairspray)
Certain medicines such as aspirin or other nonsteroidal anti-inflammatory
drugs and nonselective beta-blockers
Sulfites in foods and drinks
Viral upper respiratory infections such as colds
Exercise (physical activity)
Other health conditions—such as runny nose, sinus infections, reflux disease,
psychological stress, and sleep apnea—can make asthma more difficult to manage.
These conditions need treatment as part of an overall asthma care plan.
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Asthma Information Sheet (continued)
Asthma is different for each person. Some of the factors listed may not affect you.
Other factors that do affect you may not be on the list. Talk to your doctor about
the things that seem to make your asthma worse.
How is Asthma Diagnosed?
Primary care doctors will diagnose asthma based on medical history, a physical
exam, and results from tests. He or she also will determine the level of asthma
severity—that is, whether it's intermittent, mild, moderate, or severe. Severity level
will determine what treatment is started.
A Veteran may need to see an asthma specialist if:
Special tests are needed to be sure you have asthma.
 If a life-threatening asthma attack has occurred.
 If the Veteran needs more than one kind of medicine or higher doses of
medicine to control your asthma, or if you have overall difficulty getting your
asthma well controlled.
 If the Veteran is thinking about getting allergy treatments
Medical History
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The doctor may ask about family history of asthma and allergies. He or she also
may ask about the presence of asthma symptoms, and when and how often they
occur. The doctor will also want to know if the symptoms seem to happen only
during certain times of the year or in certain places, or if they get worse at night.
The doctor also may want to know what factors seem to set off symptoms or worsen
them. The doctor may ask about related health conditions that can interfere with
asthma management. These conditions include a runny nose, sinus infections, reflux
disease, psychological stress, and sleep apnea.
Physical Exam
The doctor will listen to the Veteran’s breathing and look for signs of asthma or
allergies. These signs include wheezing, a runny nose or swollen nasal passages,
and allergic skin conditions such as eczema. Keep in mind that someone can still
have asthma even if these signs aren’t present on the day of the examination.
Diagnostic Tests
Lung Function Test: The doctor will use a test called spirometry to check how the
lungs are working. This test measures how much air a patient can breathe in and
out. It also measures how fast the patient can blow air out. The doctor also may
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Asthma Information Sheet (continued)
give the patient medicines and then test again to see whether the results have
improved. If the starting results are lower than normal and improve with the
medicine, and if your medical history shows a pattern of asthma symptoms, your
diagnosis will likely be asthma.
Other Tests: Your doctor may order other tests if he or she needs more information
to make a diagnosis. Other tests may include:
 Allergy testing to find out which allergens may be involved, if any.
 A test to measure how sensitive the airways are. This is called a
bronchoprovocation test. Using spirometry, this test repeatedly measures
lung function during physical activity or after receiving increasing doses of
cold air or a special chemical to breathe in.
 A test to show whether another disease with the same symptoms as asthma,
such as reflux disease, vocal cord dysfunction, or sleep apnea may be
present.
 A chest x-ray or an EKG (electrocardiogram). These tests will help find out
whether a foreign object or other disease may be causing asthma symptoms.
How Is Asthma Treated and Controlled?
Asthma is a long-term disease that can't be cured. The goal of asthma treatment is
to control the disease. Good asthma control will:
Prevent chronic and troublesome symptoms such as coughing and shortness of
breath
 Reduce the need for quick-relief medicines (see below)
 Help maintain good lung function
 Let the patient maintain normal activity levels and sleep through the night
 Prevent asthma attacks that could result in emergency room visits or hospital
admissions.
To reach this goal, patients should actively partner with their doctor to manage
asthma. Taking an active role to control asthma involves working with the doctor
and other clinicians on the health care team to create and follow an asthma action
plan. It also means avoiding factors that can make asthma flare up and treating
other conditions that can interfere with asthma management. An asthma action plan
gives guidance on taking your medicines properly, avoiding factors that worsen you
asthma, tracking your level of asthma control, responding to worsening asthma, and
seeking emergency care when needed.
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Asthma Information Sheet (continued)
Asthma is treated with two types of medicines: long-term control and quick-relief
medicines. Long-term control medicines help reduce airway inflammation and
prevent asthma symptoms. Quick-relief, or "rescue," medicines relieve asthma
symptoms that may flare up.
Initial asthma treatment will depend on how severe the disease is. Follow-up asthma
treatment will depend on how well the patient’s asthma action plan is working to
control symptoms and prevent asthma attacks. The level of asthma control can vary
over time and with changes in home, school, or work environments that alter how
often exposures to asthma-worsening factors occur. The doctor may need to
increase medications if the asthma doesn't stay under control. On the other hand, if
the asthma is well controlled for several months, the doctor may be able to
decrease the medication. These adjustments either up or down will help to maintain
the best control possible with the least amount medication.
Following an Asthma Action Plan
Patients can work with their doctor to create a personal written asthma action plan.
The asthma action plan shows the daily treatment, such as what kind of medicines to
take and when to take them. The plan explains when to call the doctor or go to the
emergency room. The Behavioral Health Provider can encourage the patient to
follow through with the plan and provide encouragement and/or corrective actions.
See the National Heart, Lung, and Blood Institute's (NHLBI's) Asthma Action Plan for
a sample plan.
Avoid Things That Can Worsen Your Asthma
A number of common things (sometimes called asthma triggers) can set off or
worsen asthma symptoms. Once these factors are known, a patient can take steps
to control many of them. (For more information on asthma triggers, see "What Are
the Signs and Symptoms of Asthma?")
For example, if exposure to pollens or air pollution makes asthma worse, patients
may try to limit time outdoors when the levels of these substances are high in the
outdoor air. If animal fur sets off asthma symptoms, pets with fur should be kept
out of the home or bedroom. The NHLBI offers many useful tips for controlling things
that make your asthma worse. (See page 2 of NHLBI's Asthma Action Plan.)
If asthma symptoms are clearly linked to allergies, and exposure to those allergens
can’t be avoided, then the doctor may advise the patient to get allergy shots for
the specific allergens that bother the asthma. Patients may need to see a specialist
if they're thinking about getting allergy shots. These shots may lessen or prevent
asthma symptoms, but they can't cure asthma.
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Asthma Information Sheet (continued)
Several health conditions can make asthma more difficult to manage. These
conditions include runny nose, sinus infections, reflux disease, psychological stress,
and sleep apnea. These conditions will likely be treated as well.
Medicines
Doctors will consider many things when deciding which asthma medicines are best
for the patient. Doctors usually use a stepwise approach to prescribing medicines.
Asthma medicines can be taken in pill form, but most are taken using a device
called an inhaler. An inhaler allows the medicine to go right to the lungs. Not all
inhalers are used the same way. Ask the doctor and other clinicians on the health
care team can show the patient the right way to use an inhaler.
Long-Term Control Medicines
Most people who have asthma need to take long-term control medicines daily to
help prevent symptoms. The most effective long-term medicines reduce airway
inflammation. These medicines are taken over the long term to prevent symptoms
from starting. They don't give you quick relief from symptoms.
Inhaled Corticosteroids. Inhaled corticosteroids are the preferred medicines
for long-term control of asthma. These medicines are the most effective longterm control medicine to relieve airway inflammation and swelling that makes
the airways sensitive to certain substances that are breathed in. Reducing
inflammation helps prevent the chain reaction that causes asthma symptoms.
Most people who take these medicines daily find they greatly reduce how
severe symptoms are and how often they occur.
Inhaled corticosteroids are generally safe when taken as prescribed. They're
very different from the illegal anabolic steroids taken by some athletes.
Inhaled corticosteroids aren't habit-forming, even if taken every day for
many years. But, like many other medicines, inhaled corticosteroids can have
side effects. Most doctors agree that the benefits of taking inhaled
corticosteroids and preventing asthma attacks far outweigh the risks of side
effects.
One common side effect from inhaled corticosteroids is a mouth infection
called thrush. Often patients can use a spacer or holding chamber to avoid
thrush. A spacer or holding chamber is attached to the inhaler when taking
medicine to keep the medicine from landing in the mouth or on the back of
the throat. Rinsing the mouth out with water after taking inhaled
corticosteroids also can lower the risk of thrush.
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Asthma Information Sheet (continued)
With severe asthma, patients may have to take corticosteroid pills or liquid
for short periods to get asthma under control. If taken for long periods, these
medicines may increase the chance of cataracts and osteoporosis.
Other Long-term Control Medicines. Other long-term control medicines include:
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Inhaled long-acting beta2-agonists. These medicines open the airways and
may be added to low-dose inhaled corticosteroids to improve asthma control.
An inhaled long-acting beta2-agonist shouldn't be used alone.
Leukotriene modifiers. These medicines are taken by mouth. They help block
the chain reaction that increases inflammation in the airways.
Cromolyn and nedocromil. These inhaled medicines also help prevent
inflammation and can be used to treat asthma of mild severity.
Theophylline. This medicine is taken by mouth and helps open the airways.
If the doctor prescribes a long-term control medicine, it should be taken every
day to control asthma. Asthma symptoms will likely return or get worse if the
medication is stopped.
Quick-Relief Medicines
All people who have asthma need a quick-relief medicine to help relieve asthma
symptoms that may flare up. Inhaled short-acting beta2-agonists are the first
choice for quick relief. These medicines act quickly to relax tight muscles around
the airways during a flare-up. This allows the airways to open up so air can flow
through them.
Quick-relief medication is taken when asthma symptoms are first noticed. If
patients are using this medicine more than 2 days a week, they should talk with
their doctor about how well controlled the asthma really is. You shouldn't use
quick-relief medicines in place of prescribed long-term control medicines. QuickEmergency Care
Most people who have asthma can safely manage their symptoms by following the
steps for worsening asthma provided in the asthma action plan. Patients should call
their doctor for advice if:
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Medicines don't relieve an asthma attack.
If peak flow is less than half of personal best peak flow number.
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Asthma Information Sheet (continued)
Call 9–1–1 for an ambulance to take you to the emergency room of your local
hospital if:
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You have trouble walking and talking because you're out of breath.
You have blue lips or fingernails.
At the hospital, you will be closely watched and given oxygen and more medicines,
as well as medicines at higher doses than you take at home. Such treatment can
save your life.
Asthma Treatment for Special Groups
The treatments described in this section generally apply to all people who have
asthma. However, some aspects of treatment differ for people in certain age
groups and those who have special needs.
Older Adults
Doctors may need to adjust asthma treatment for older adults who take certain
other medicines, such as beta blockers, aspirin and other pain relievers, and antiinflammatory medicines. These medicines can prevent asthma medicines from
working properly and may worsen asthma symptoms. Older adults may develop
weak bones from using inhaled corticosteroids, especially at high doses. Talk to
your doctor about taking calcium and vitamin D pills and other ways to help keep
your bones strong.
People Having Surgery
Asthma may add to the risk of having problems during and after surgery. For
instance, intubation may cause an asthma attack. Patients should tell their surgeon
about their asthma. The surgeon can take steps to lower your risks, such as giving
you asthma medicines before or during surgery.
References and Further Information
National Heart Lung and Blood Institute
Internet: http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_WhoIsAtRisk.html
These Information Sheets are designed to provide a brief overview of various medical conditions.
Referring to the Information Sheets may help you communicate more effectively with other
members of the Primary Care Team. The Information Sheets are by no means an exhaustive
description of the disorders. If you need additional information, please engage in a more
detailed search. Don’t forget to consult with other members of the Primary Care Team. They are
an invaluable source of information!
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